-
Surgical Neurology International 2022Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore,... (Review)
Review
BACKGROUND
Our hypothesis was that lumbar adhesive arachnoiditis (AA)/chronic lumbar AA (CAA) are clinical diagnoses that do not require radiographic confirmation. Therefore, patients with these syndromes do not necessarily have to demonstrate significant radiographic abnormalities on myelograms, MyeloCT studies, and/or MR examinations. When present, typical AA/CAA findings may include; central or peripheral nerve root/cauda equina thickening/clumping (i.e. latter empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/Myelo-CT studies.
METHODS
We reviewed 3 articles and 7 clinical series that involved a total of 253 patients with AA/CAA to determine whether there was a significant correlation between these clinical syndromes, and myelographic, Myelo-CT, and/or MR imaging pathology.
RESULTS
We determined that patients with the clinical diagnoses of AA/CAA do not necessarily exhibit associated radiographic abnormalities. However, a subset of patients with AA/CAA may show the classical AA/CAA findings of; central or peripheral nerve root/cauda equina thickening/clumping (empty sac sign), arachnoid cysts, soft tissue masses in the subarachnoid space, and/or failure of nerve roots to migrate ventrally on prone MR/ Myelo-CT studies.
CONCLUSION
Patients with clinical diagnoses of AA/CAA do not necessary show associated neuroradiagnostic abnormalities on myelograms, Myelo-CT studies, or MR. Rather, the clinical syndromes of AA/CAA may exist alone without the requirement for radiolographic confirmation.
PubMed: 36447842
DOI: 10.25259/SNI_943_2022 -
Journal of Veterinary Internal Medicine Jan 2023We describe the unique clinical presentation of a central nervous system neoplasm in a 6-month-old draft horse cross gelding. Based on the neurologic examination at...
We describe the unique clinical presentation of a central nervous system neoplasm in a 6-month-old draft horse cross gelding. Based on the neurologic examination at admission, neurolocalization was most consistent with a mildly asymmetric cervical, multifocal, or diffuse myelopathy. Mild vestibular involvement also was considered, but no cranial nerve deficits were observed. The gelding was negative for Sarcocystis neurona or Neospora hughesi based on paired serum and cerebrospinal fluid (CSF) samples analyzed, with no evidence of cervical compression based on contrast myelography. The horse was euthanized because of progression of clinical signs. At necropsy, a mass was identified associated with the cerebellum, and histopathology was consistent with medulloblastoma, which has not been reported previously in the horse.
Topics: Animals; Horses; Male; Sarcocystosis; Coccidiosis; Medulloblastoma; Encephalomyelitis; Horse Diseases; Antibodies, Protozoan; Sarcocystis; Spinocerebellar Degenerations; Cerebellar Neoplasms; Ataxia
PubMed: 36433686
DOI: 10.1111/jvim.16592 -
Journal of Neurosurgery. Case Lessons Nov 2022Superficial hemosiderosis (SS) of the central nervous system is a rare condition that is caused by chronic, repeated hemorrhage into the subarachnoid space. The...
BACKGROUND
Superficial hemosiderosis (SS) of the central nervous system is a rare condition that is caused by chronic, repeated hemorrhage into the subarachnoid space. The subsequent deposition of hemosiderin in the brain and spinal cord causes neurological deterioration. In this report, the authors describe a repair procedure for SS associated with a dural defect in the thoracic spine.
OBSERVATIONS
A 75-year-old man presented with tinnitus symptoms that began about 1 year prior. Subsequently, his hearing loss progressed, and he gradually became unsteady on walking. Magnetic resonance imaging (MRI) of the head showed diffuse hemosiderin deposition on the surface of the cerebellum. Thoracic MRI showed ventral cerebrospinal fluid leakage of T2-7, and computed tomography myelography showed leakage of contrast medium that appeared to be a dural defect. Dural closure was successful, and MRI showed decreased fluid collection ventral to the dura. The patient's symptoms of wobbliness on walking and tinnitus improved dramatically from the postoperative period.
LESSONS
Dural abnormalities of the spine must always be considered as one of the causes of SS. Early dural closure is an effective means of preventing the progression of symptoms.
PubMed: 36377127
DOI: 10.3171/CASE22315 -
Journal of Neurosurgery. Case Lessons Nov 2022Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts.
BACKGROUND
Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts.
OBSERVATIONS
A 60-year-old female presented to our hospital with a spastic gait and numbness in both palms. Magnetic resonance imaging (MRI) revealed a spinal cyst from C4 to T4 compressing the spinal cord. Computed tomography myelography revealed a fistula at C4-5 and C5-6 that connected the cyst along the right C5 and C6 root sleeves. The cyst was located within the dura mater, and communication with the arachnoid space was achieved using a shunt tube. There was partial spastic gait amelioration after the procedure, but the patient experienced a relapse 2 months postoperation. A repeat procedure was performed without a shunt tube to allow greater communication between the cyst and the subarachnoid space. After this, marked improvement in gait function was observed, and MRI showed a significant reduction in cyst volume.
LESSONS
Interdural spinal meningeal cysts are rare. When the interdural cyst cannot be removed entirely, surgery may be appropriate for providing a shunt tube or establishing communication between the cyst and arachnoid space to maintain the circulation of cerebrospinal fluid collected in the cyst cavity.
PubMed: 36345207
DOI: 10.3171/CASE22198 -
Zhongguo Xiu Fu Chong Jian Wai Ke Za... Oct 2022To investigate the relationships between the bony structures, nerve, and indentations of ligamentum flavum of the upper lumbar spine by using CT three-dimensional...
OBJECTIVE
To investigate the relationships between the bony structures, nerve, and indentations of ligamentum flavum of the upper lumbar spine by using CT three-dimensional reconstruction technique, in order to guide the unilateral biportal endoscopy (UBE) technique via contralateral approach in the treatment of upper lumbar disc herniation (ULDH).
METHODS
Twenty-one ULDH patients who were admitted between June 2019 and July 2021 and met the selection criteria were selected as the research subjects. There were 12 males and 9 females with an average age of 62.1 years (range, 55-72 years). The disease duration was 1-12 years (mean, 5.7 years). There was 1 case of L , 4 cases of L , and 16 cases of L . The CT myelography data of T -S segment was saved in DICOM format and imported into Mimics21.0 software for three-dimensional reconstruction. The relationship between the intersection (point Q) of spinous process and the inferior margin of lamina, the indentation of superior margin of ligamentum flavum, the inferior margin of nerve root origin, intervertebral space, and foramen were observed. The Mimics21.0 software was used to create a 3-mm-diameter cylinder to simulate the UBE channel and measure its abduction angle (∠b1), as well as measure the following lumbar vertebra-related indicators: in L -L segments, the vertical distance from the point Q to the inferior margin of the contralateral lumbar pedicle of the same lumbar vertebra (a1), the superior margin of the contralateral pedicle of the lower lumbar vertebra (a2), the lower endplate of the same lumbar vertebra (a3), the upper endplate of the lower lumbar vertebra (a4); the vertical distance from the lower endplate of lumbar vertebra to the inferior margin of the lumbar pedicle (c1), the vertical distance from the upper endplate of the lower lumbar vertebra to the superior margin of the lumbar pedicle (c2); the vertical distance from the inferior margin of the nerve root origin to the superior margin (d1) and the inferior margin (d2) of the lumbar pedicle, respectively; the vertical distance from the intersection (point P) of the indentation of superior margin of ligamentum flavum and the medial margin of the lumbar pedicle to the superior margin (e1) and the inferior margin (e2) of the lumbar pedicle, respectively; the horizontal distance from the lateral margin of the dural mater (f1) and the narrowest part of the lumbar isthmus (f2) to the facet joint space, respectively. Thirteen of the patients included in the study chose the UBE surgery via contralateral approach. There were 8 males and 5 females with an average age of 63.3 years (range, 55-71 years). The disease duration was 2-12 years, with an average of 6.2 years. There were 3 cases of L and 10 cases of L . The perioperative complications and surgical decompression were recorded. And the effectiveness were evaluated by visual analogue scale (VAS) score, Oswestry disability index (ODI), and short form-36 health survey (SF-36) score.
RESULTS
The imaging results showed that there was no significant difference in a1, a3, a4, e1, e2, f1, and f2 between segments ( >0.05), and there were significant differences ( <0.05) in a2 and c2 between L and L segments, in ∠b1 and d2 between L , L segments and L segments, and in c1 and d1 between L and L , L segments. The 87.30% (110/126) of point Q of L -L segments corresponded to the inferior articular process, and 78.57% (99/126) of the lower endplate corresponded to the level of the isthmus. All 13 patients completed the UBE surgery via contralateral approach, and none were converted to open surgery. All patients were followed up 12-17 months (mean, 14.6) months. The VAS score of low back pain and leg pain, ODI, and SF-36 score at 6 and 12 months after operation significantly improved when compared with those before operation ( <0.05), and further improved at 12 months after operation when compared with 6 months after operation ( <0.05). The imaging review results showed that the herniated disc was removed and the dura mater was decompressed adequately.
CONCLUSION
The point Q, the superior margin of ligamentum flavum, and lumbar pedicle can be used as the markers for the treatment of ULBD with UBE surgery via contralateral approach, making the procedure safer, more precise, and more effective.
Topics: Male; Female; Humans; Middle Aged; Intervertebral Disc Displacement; Spinal Fusion; Lumbar Vertebrae; Endoscopy; Lumbosacral Region; Treatment Outcome; Retrospective Studies
PubMed: 36310457
DOI: 10.7507/1002-1892.202205017 -
Journal of Neurosurgery. Case Lessons Apr 2022Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may...
BACKGROUND
Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies.
OBSERVATIONS
Case 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5-S1. Multilevel lumbar laminectomies and facetectomies with an L5-S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4-5 and L5-S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery.
LESSONS
Spine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.
PubMed: 36303488
DOI: 10.3171/CASE21566 -
NMC Case Report Journal 2022Arachnoiditis ossificans (AO) is a rare disease, wherein ossified lesions in the subarachnoid space obstruct the flow of spinal fluid or compress the spinal cord,...
Arachnoiditis ossificans (AO) is a rare disease, wherein ossified lesions in the subarachnoid space obstruct the flow of spinal fluid or compress the spinal cord, thereby causing myelopathy. Here we describe a rare case of AO and discuss the diagnosis and treatment strategies for this disease. A 66-year-old man with a history of subarachnoid hemorrhage presented with gait disturbance and dysuria for 7 months. Spinal magnetic resonance imaging and computed tomography (CT) myelography showed syringomyelia at the T5-T8 level and dorsally tethered spinal cord at the T8-T10 level. Preoperative noncontrast CT was not performed. The patient was diagnosed with adhesive arachnoiditis and underwent arachnoidolysis. However, intraoperative findings showed the presence of ossification lesions on the dorsal surface of the spinal cord, and intraoperative ultrasound (IOU) showed a hyperintense lesion with acoustic shadowing on the dorsal surface of the spinal cord, with limited visibility of the spinal cord. After removal of the lesions, IOU showed untethered and well-decompressed spinal cord and restoration of cerebrospinal fluid pulsation. Based on these findings, the patient was finally diagnosed with AO, which is an extremely rare disease, with an unknown frequency of occurrence. Therefore, all patients with adhesive spinal arachnoiditis require a preoperative noncontrast CT scan to evaluate for ossification lesions. In this case, we were fortunate to be able to treat AO with IOU, which demonstrated specific findings.
PubMed: 36263188
DOI: 10.2176/jns-nmc.2022-0036 -
Brain & Spine 2022Discogenic microspurs are calcified outgrowths from the intervertebral disc which can perforate the dura, causing a leak of cerebrospinal fluid (CSF). Spontaneous leaks...
INTRODUCTION
Discogenic microspurs are calcified outgrowths from the intervertebral disc which can perforate the dura, causing a leak of cerebrospinal fluid (CSF). Spontaneous leaks of the CSF present a recognized cause of spontaneous intracranial hypotension (SIH). Moreover, subdural hematomas (SDH) are a potentially severe complication of SIH.
RESEARCH QUESTION
We present a case of a bilateral subdural hematoma without orthostatic headaches caused by a discogenic microspur protruding from the T1-2 intervertebral disc. The microspur is conjectured to be the culprit of the leak by ventrally perforating the dura and catalyzing the causal chain leading to the formation of the subdural hemorrhage.
MATERIAL AND METHODS
A 79-year woman noticed a progressive gait disturbance accompanied by a decline of short-term memory over several months without experiencing orthostatic headaches. Magnetic resonance imaging (MRI) showed extensive bilateral subdural fronto-parietal hematoma, signs of CSF hypotension (dilated venous compartments), and computed tomography (CT) myelography revealed a CSF leak originating at the T1-2 level.
RESULTS
The leakage site was treated with microsurgical duraplasty leading to a regression of the symptoms and complete resolution of the subdural hematomas within five postoperative months.
DISCUSSION AND CONCLUSION
Discogenic microspurs can perforate the dura causing a CSF leak, leading to spontaneous intracranial hypotension, finally resulting in a bilateral subdural hematoma. This constellation of symptoms does not necessarily induce orthostatic headaches and can be treated with microsurgical duraplasty.
PubMed: 36248145
DOI: 10.1016/j.bas.2022.100879 -
Advances in Radiation Oncology 2022Our aim was to characterize the patterns of cerebrospinal fluid (CSF) extension in the lumbosacral spine using computed tomography (CT) myelograms to provide an evidence...
Delineating the Subarachnoid Space in the Adult Lumbosacral Spine Using Computed Tomographic Myelography: An Aid for Clinical Target Volume Delineation in Craniospinal Irradiation.
PURPOSE
Our aim was to characterize the patterns of cerebrospinal fluid (CSF) extension in the lumbosacral spine using computed tomography (CT) myelograms to provide an evidence base for clinical target volume (CTV) definition in adults receiving craniospinal irradiation.
METHODS AND MATERIALS
This was a retrospective analysis of diagnostic CT lumbar myelograms performed in 30 patients between the ages of 22 and 50. Lateral extension of CSF beyond the thecal sac was measured along each lumbar and sacral nerve root to the nearest millimeter, as was the distance of inferior extension of CSF beyond the caudal end of the thecal sac. Each patient's lateral and inferior CSF extensions were mapped onto a standardized CT data set to create a model target volume in the lumbosacral spine that would contain the aggregate observed CSF distributions from the analyzed CT myelograms. The median extension distances, interquartile ranges, and 90th percentile for distance at each level were calculated.
RESULTS
The median lateral extension of CSF along nerve roots beyond the thecal sac-as measured perpendicular to the longitudinal axis-increased from 0 mm (interquartile range [IQR], 0-4 mm) at L1 to 8 mm (IQR, 6-12 mm) at S1 and 0 mm (IQR, 0-0 mm) at S4. The 90th percentile ranged from 5 to 14 mm laterally, with a pattern partially extending into the S1 and S2 sacral foramen. Median CSF extension inferior to the caudal sac was 5 mm (IQR, 2-8 mm), with 90% of patients within 12 mm. An atlas was generated to guide CTV delineation for highly conformal radiation techniques.
CONCLUSION
These results provide information on patterns of CSF extension in the lumbosacral spine of adults and can serve as a model for CTV guidelines that balance comprehensive coverage of the CSF compartment while minimizing the dose to nontarget tissues.
PubMed: 36148369
DOI: 10.1016/j.adro.2022.100994 -
AJNR. American Journal of Neuroradiology Oct 2022We describe a technique termed "resisted inspiration" that could be used during myelography to decrease superior vena cava venous pressure and increase lumbar CSF...
We describe a technique termed "resisted inspiration" that could be used during myelography to decrease superior vena cava venous pressure and increase lumbar CSF pressure, potentially aiding in the detection of CSF-venous fistulas.
Topics: Humans; Vena Cava, Superior; Myelography; Fistula
PubMed: 36137659
DOI: 10.3174/ajnr.A7636